REGISTRATION AND PARENTAL CONSENT FORM Student Name Age Birth Date Address Male/Female Phone(______) City State Zip Code School Grade in Email Address I am the parent/guardian of ___________________ and I give my permission for him/her to participate in the activities during the All Pro Football Camp at Westfield High School in Chantilly, VA. I also give permission for my student to appear in videos & photos for future promotions. ______________________________________________________ Parent Signature / Date Who Invited You? Oneighty attendance: [ ] This is my first time to attend a Oneighty event [ ] I have been to other Oneighty events, but I don’t attend regularly [ ] I attend Oneighty regularly COST: $95 ❒ Cash ! Check (check # ) ! Credit Card (Online) Medical Information We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services and rendered to the aforementioned child pursuant to this authorization. Should it be necessary for our (my) child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs. The undersigned does also hereby give permission for our (my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by ____________________________ (Church) Hospital insurance Yes Insurance Company Policy Number Emergency Phone Number(s) Participant Father Mother Legal Guardian No Please list any allergies or special medical problems your child may have. Thank you. Signed: ___________________________________ Date Date Date Date sign up now! A FREE Football Clinic For 6th-12th graders. WHEN: Friday, June 12 6-8:30pm & Saturday, June 13 9am-noon WHERE: Westfield High School 4700 Stonecroft Blvd, Chantilly, VA 20151 HOSTED BY: Kedric Golston, jared green and other NFL players DETAILS: The All Pro Football Camp is a free non-contact skills and agility camp that will help your athlete progress in their football and character abilities on and off the field while learning from current NFL players and area high school coaches. ony: awards ceremallpro2014.eventbrite.com noon-1:30pm on Saturday@ the oneighty Youth building (4465 Brookfield Corporate Drive; Chantilly, va 20151) allprosportscamp.com